New patient questionnaire Personal informationTitle* Mr. Ms. Mrs. First name* Last name* Email Gender* Female Male Birthdate* MM slash DD slash YYYY Address* City* Province* Postal code* Preferred phone number* Alternate phone number Spouse's name Dentist Physician How were you referred to us?* Dental insuranceDo you have dental insurance?* Yes No Primary insurance company Primary policy holder name If you are not the primary policy holder, please provide their date of birth MM slash DD slash YYYY Primary group or policy number Primary employee, ID, or certificate number Do you have a secondary dental insurance policy? Yes No Secondary insurance company Secondary policy holder name If you are not the secondary policy holder, please provide their date of birth MM slash DD slash YYYY Secondary group or policy number Secondary employee, ID, or certificate number Denture historyDo you currently have a denture(s)?* Yes No What type of upper denture do you have? None Partial upper denture Complete upper denture Implant-supported upper denture When was your most recent upper denture made? How many upper dentures have you had?What type of lower denture do you have? None Partial lower denture Complete lower denture Implant-supported lower denture When was your most recent lower denture made?How many lower dentures have you had?Who made your denture(s)? Dentist Denturist Do your gums get sore under your denture(s)? Yes No Do you brush your gums under your denture(s)? Yes No Do you wear your denture(s) to bed at night? Yes No Does your denture(s) fit well? Yes No Are you happy with the appearance of your denture(s)? Yes No What don't you like about the appearance of your denture(s)? Are there any foods you have trouble eating? Yes No What foods do you have trouble eating? Do you use denture adhesive? Yes No What changes would you like to see in your new denture(s)If you have never worn dentures, what do you know about them so far?Dental historyWhen was your last visit with a dentist?* At that visit, what procedure(s) did you have done? Have you ever had any complications following a dental procedure?* Yes No Have you had dental x-rays in the past 2 years?* Yes No Do you have any dental work in progress at this time?* Yes No If yes, please describe. Do you have sensitive teeth?* Yes No I have no remaining teeth If yes, please describe. Do your gums bleed?* Yes No Do you often have a bad, unpleasant, or strange taste in your mouth?* Yes No If yes, please describe. Do you experience pain, clicking, or popping in your jaw joint?* Yes No Do you experience facial, neck, or head pain?* Yes No Do you grind or clench your teeth?* Yes No Do you have dental implants?* Yes No Have you ever had an accident or trauma to your neck or jaw?* Yes No If yes, please describe. Do you currently have any sore spots in your mouth?* Yes No Do you have any habits that affect your mouth?* Yes No If yes, please describe. Medical historyDo you have a family physician that you see regularly?* Yes No Are you under the care of a physician for a specific health concern?* Yes No If yes, please describe. Have you recently lost or gained a significant amount of weight?* Yes No Do you smoke or use chewing tobacco?* Yes No Do you have frequent indigestion?* Yes No Are you pregnant?* Yes No Do you have any of the following health issues? Please select all that apply.* Alcohol or drug dependency Angina pectoris Anorexia Arthritis Asthma Bleeding disorder Bulimia Cancer Chemotherapy or radiation Cholesterol problems Cold sores COPD Depression Diabetes Type 1 Diabetes Type 2 Difficulty breathing Dizziness or fainting Emphysema Epilepsy or seizures Fibromyalgia Heart attack Heart disease Heart murmur Hepatitis A Hepatitis B Hepatitis C Herpes virus High blood pressure HIV or AIDS HPV Immune deficiency Kidney disease Kidney stones Liver disease Low blood pressure Nervousness Psychological disorder Rheumatic fever Sexually transmitted disease Stroke Tuberculosis No health issues Do you have any of the following allergies? Please select all that apply. Drug allergies Environmental allergies Latex allergy Other Please list all current medications.*Have you ever experienced a bad reaction to any of the following medications? Please select all that apply. Anaesthethic Barbiturates (sleeping pills) Codeine Cortisone Penicillin Sulphonamides (sulfa drugs) Tranquilizers Other Have you had any of the following surgeries? Please select all that apply. Artificial heart valve Artificial joint replacement Heart surgery Organ transplant Pacemaker Other Have you ever had a serious illness that required hospitalization?* Yes No Do you have any other health issues which have not already been addressed in this questionnaire?*Click here to indicate that you hereby certify the information you are submitting to be complete and accurate.* Yes, my information is complete and accurate I consent to the collection, use, and disclosure of my Personal Information as set out in the Terms of Patient Consent*Full Terms can be reviewed here Yes, I consent CAPTCHA Δ
